|Year : 2018 | Volume
| Issue : 2 | Page : 67-73
Medicinal plants use by elderly people in Kashan, Iran
Mohsen Adib-Hajbaghery, Saeedeh Rafiee
Trauma Nursing Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
|Date of Web Publication||22-Mar-2018|
Dr Mohsen Adib-Hajbaghery
Trauma Nursing Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan
Source of Support: None, Conflict of Interest: None
Background: There is limited information about the use of medicinal plants (MPs) by older adults in Middle East countries, including Iran. Objective: This study aimed to assess the MP use by older adults in Kashan, Iran. Methods: A cross-sectional study was conducted on 770 older adults who were randomly selected from different areas of Kashan, Iran. A questionnaire was used to gather the data. The data were described using the measures of descriptive statistics and analyzed via the Chi-square and the Fisher's exact tests. Results: Totally, 67.8% of participants used MPs. MPs were used, respectively, for abdominal pain, temperament modification, tranquilization, constipation, and common cold. Significant statistical relationships were found between MP use and variables such as gender, having hyperlipidemia, employment status, belief in the effectiveness of the MPs, and the level of knowledge about them. Conclusion: Older adults widely use MPs. Public education programs should be implemented to inform people, particularly elderly people, about the risks associated with the over-the-counter use of MPs and their interactions with conventional medications.
Keywords: Complementary medicine, Elderly, Medicinal plants
|How to cite this article:|
Adib-Hajbaghery M, Rafiee S. Medicinal plants use by elderly people in Kashan, Iran. Nurs Midwifery Stud 2018;7:67-73
| Introduction|| |
Despite considerable advances in conventional medicine, more and more people are resorting to complementary therapies., Medicinal plants (MPs) are the main components of complementary medicine  and include a wide range of plants which are used to prevent or treat illnesses.
It is reported that 80% of people around the world, particularly in developing countries, use MPs., For instance, 82.6% of people in Saudi Arabia use MPs for gastrointestinal problems and 42.3% for neurological disorders. Furthermore, a study showed that the rate of MP use in Iran is around 71.5%. Iran has a rich diversity of plants, including MPs. Iranian ancestors have also been among the pioneers of medicine and herbal medicine in the world.
Alongside with their therapeutic effects, MPs may have some side effects. Yet, most people are unaware of the potential side effects  and that excessive or inappropriate use of MPs may cause serious health problems, particularly among children, elderly people, and pregnant women.
The probability of developing chronic health conditions increases with age. Therefore, many older adults suffer from a wide range of chronic conditions. Studies show that a majority of elderly patients with chronic conditions who are dissatisfied with their treatment outcomes resort to traditional treatments such as MPs to alleviate their symptoms., However, age-related impairments in cardiac output and liver and kidney functions increase the risk of experiencing serious drug side effects and interactions among elderly people.
To the best of our knowledge, although different studies have evaluated MP use by diabetic patients, women, pregnant women, and health-care providers, little is known about MP use by older adults in Iran. Only a study in Iran on 400 older adults showed that 74% of them used MPs. On the other hand, studies into the factors behind MP use by older adults reported contradictory results. For instance, a study reported female gender and low literacy, while another reported old age and rural residence as the significant factors predicting MP use. Given the effects of culture and living area on the use of MPs, this question comes to mind that “What is the prevalence of MP use among elderly people in Iran and what are the contributing factors?”
Given the lack of information about elderly people's use of MPs in Iran and contradictory results about factors behind the use of these plants, this study was conducted to assess the MP use by older adults and its contributing factors in Kashan, Iran.
| Methods|| |
Study design and participants
This cross-sectional study was done from December 2016 to March 2017 on older adults who lived in Kashan, Iran. Kashan is a city located 250 km south to Tehran, the capital of Iran, with a population of 364,482 people. There are 14 primary health-care centers in the city.
The size of the study sample was estimated using the results of an earlier study by Akbari et al., who reported that 74% of 400 older adults in their study used MPs. Therefore, with a proportion of 0.74 and a confidence level of 0.95, the sample size was estimated to be 770.
Participants were recruited via the cluster sampling. Accordingly, Kashan city was divided into five regions, i.e., center, north, east, south, and west, and two primary health-care centers were randomly selected from each region. Then, a complete list of the names of older adults covered by each selected center was created and the names were numbered. Thereafter, the number of older adults to be recruited from each center was calculated based on the total number of older adults covered by that center. After that, a proportionate number of eligible older adults were selected from each center using a table of random numbers. Eligibility criteria were Iranian nationality, an age of 60 years or more, ability to verbally communicate in Persian, and having no known cognitive disorders such as Alzheimer's disease. The addresses and the phone numbers of the selected people were retrieved from their medical records kept in the centers. Finally, the second author referred to their homes and collected the necessary data.
Data collection tool was a questionnaire made by the researchers and amended by experts' comments. The questionnaire contained 24 items in three parts. The first part comprised ten items on demographic characteristics, i.e., age, gender, number of children, insurance, source of income, history of chronic conditions, and marital, educational, employment, and economic status. The nine items of the second part were on MP use, the source of information about MPs, the source which recommended MP use, the place for buying MPs, receiving education from the MP sellers, treating physician's awareness of MP use, simultaneous use of MPs and conventional medications, belief in the effectiveness of MPs, and the level of knowledge about MPs. The third part contained three items on the names of the used MPs, the reason for using them, and the reason for stopping their use. Finally, two questions were included at the end of the questionnaire about the use of unfamiliar plants. Ten experts in nursing, medicine, and Iranian Traditional Medicine assessed and approved the fluency and appropriate wording of the items and the content validity of the questionnaire. Reliability assessment was done through the test–retest method, during which the questionnaire was completed twice for ten elderly people with a 15-day interval. The test–retest agreement coefficient was 0.95. The questionnaire was filled out through holding a personal interview at each participant's home door.
The Ethics Committee of Kashan University of Medical Sciences, Kashan, Iran, approved this study (approval code: IR.KAUMS.REC.1395.88). Introduction and permission letters were obtained from the same university and were provided to the selected health-care centers. All participants were provided with information about the aim of the study and were assured that their information would be handled confidentially. Questionnaires were anonymous and informed consent was obtained from each participant.
Statistical data analysis was performed via the SPSS software version 13.0 (SPSS Inc., Chicago, IL, USA). The data were described using the measures of descriptive statistics (i.e., frequency, percent, mean, and standard deviation). Moreover, the Chi-square and the Fisher's exact tests were conducted to analyze the relationship between MP use and categorical and ordinal variables.
| Results|| |
Most participants were female (51.9%), married (80.5%), illiterate (47.8%), and pensioner (66.3%). Moreover, 43.2% of them had medium economic status. They ranged in age from 60 to 98 years, with a mean of 68.59 ± 7.98 years [Table 1]. The most prevalent chronic condition among them was hypertension (44.5%) [Table 1].
Around 67.8% of participants (i.e., 62.4% of males and 72.8% of females) reported MP use. The most commonly used MPs were mint (Mentha viridis) (38.8%), ginger (Zingiber officinale) (27.9%), and bugloss (Echium amoenum) (27.2%). MPs were respectively used for abdominal pain, temperament modification, tranquilization, constipation, and common cold [Table 2].
|Table 2: The most commonly used medicinal plants along with the main reasons for their usea|
Click here to view
Some participants (2.7%) reported that after using MPs for several times, they stopped their use due to their ineffectiveness or side effects. Most participants (94.3%) bought MPs from traditional herbalist's shops and 33.3% of them reported that they had only occasionally received necessary MP-related information from herbalists. Other participants either took MPs from physicians' private offices (2.5%) or picked them from outdoor environment (3.2%).
In addition, 37.5% of the participants referred to friends and relatives as the sources which recommended MP use. Moreover, 61.1% of them noted that their relatives were their most important source of MP-related information. Around half of the participants (49.4%) almost always used MPs simultaneously with conventional medications, and most of them (68%) had not told their treating physicians about their MP use [Table 3].
|Table 3: Sources of recommendation, sources of information, rate of use with conventional medications, and rate of reporting to the physician|
Click here to view
Around 48.6% of participants strongly and 31.2% moderately believed that MPs were effective in managing health problems. MP use was significantly related to gender, education level, employment status, belief in MP effectiveness, MP-related knowledge, and history of hyperlipidemia [P < 0.05; [Table 4]. Around 46.4% of participants had resorted to MP use due to their own or their friends' previous experiences of MP use.
|Table 4: The relationship of medicinal plant use with demographic and health-related characteristics|
Click here to view
| Discussion|| |
Findings indicated that 67.8% of elderly people used MPs. Similarly, Azizi-Fini et al., Ameri et al., and Akbari et al. reported the high prevalence of MP use among Iranians. MPs are among the cornerstones of Iranian Traditional Medicine, and despite the wide prevalence of conventional medicine in the past 50 years, most Iranians still believe in the effectiveness of traditional therapies., Thus, the high prevalence of MP use in the present study can be attributed to the cultural background and the traditional beliefs of Iranians. Moreover, MPs are easily accessible in Iran and people can buy them from widespread herbalist's shops and grocery stores which sell these products over the counter and without any supervision. Besides, Kashan, the city in which the study was done, is the main center for MP harvesting and processing in Iran, and a large part of people in this city are involved in traditional harvesting and processing of MPs. Therefore, MP use is common among them.
The study findings also showed that about half of the participants strongly believed in the effectiveness of MPs in managing health problems. Moreover, participants' own experiences as well as their friends' and relatives' experiences considerably affected their resort to MPs. Other studies in Iran also showed that most Iranian have strong beliefs in the effectiveness and the greater safety of MPs compared to conventional medications., Moreover, studies in Iran,, Sudan, and Jordan  reported relatives and friends as the main sources of MP-related information. These findings not only show the great public interest in MPs in developing countries but also are indicative of their blind trust in laypeople's recommendations about MP effectiveness and safety. Another factor behind older adults' great use of MPs may be their lower costs compared with conventional medicinal therapies. Consequently, health-care managers and authorities need to implement programs to expand insurance coverage particularly for chronically ill elderly patients and also to inform the public about the serious side effects of MPs and the necessity of using them under close expert supervision.
Most participants in the present study bought MPs from traditional herbalist's shops but rarely received MP-related information from herbalists. Moreover, more than half of them did not report their MP use to their treating physicians while half of them simultaneously used MPs and conventional medications. These findings are in congruence with the findings of studies in different areas of Iran,,, Sudan, Uganda, and Jordan. These findings denote that most of older adults used MPs over the counter. Moreover, it seems that herbalists do not provide MP users with adequate information about how to use MPs and how to monitor and manage their side effects. Therefore, programs for public education about MPs and supervision of herbalist's shops are needed to improve the safety of MP use. On the other hand, older adults avoidance from reporting their MP use to their treating physicians can be due to different factors such as their misconceptions about the safety of MPs,, their concerns over their physicians' negative reactions to their MP use,, and physicians' poor communication skills or limited time for taking comprehensive medical history from their patients.,, Therefore, besides public education, health-care providers, particularly physicians and nurses, should also be provided with comprehensive educations about MPs and their side effects and should be required to ask and warn their clients about the over-the-counter use of MPs.
The study findings also showed that around half of the participants simultaneously used MPs and conventional medications. This practice may be due to older adults' lack of knowledge about the interactions of these plants with conventional medications. Izzo also noted that the interactions of MPs with conventional medications have been reported in many studies, with the highest prevalence related to warfarin. These findings also highlight the importance of reporting MPs by older adults to their treating physicians and the importance of taking a comprehensive MP use history by physicians from elderly people. Unfortunately, our physicians usually pay less time for history taking. In such a condition, nurses should pay special attention to this crucial task and take a comprehensive health history (especially about MP use) of their elderly patients.
The findings of the present study also showed that the most common reasons for MP use by older adults were tranquilization, temperament modification, abdominal pain, and common cold. Similarly, Akbari et al. reported common cold, stomach pain, headache, and leg pain as the most common reasons behind MP use. However, a study in Germany reported that children and adolescents used MPs mainly for managing cough and common cold. This contradiction may be due to the differences in the samples and the cultural contexts in these studies.
The most commonly used MPs by our elderly participants were M. viridis, Z. officinale (ginger), and E. amoenum. Akbari et al. also reported that their participants mainly used thyme, bugloss, Sisymbrium-seeds, mugwort, licorice, a type of lavender, and Ziziphus vulgaris. A study in Ethiopia also found that the most commonly used MPs by Ethiopian pregnant women were garlic and ginger. In Iranian traditional medicine, M. viridis is used for promoting digestion and alleviating abdominal pain, nausea, and muscle cramps, while ginger is recommended for a wide spectrum of health problems such as diabetes mellitus, hypertension, and cancer. Most of our participants used mint for abdominal pain and ginger for temperament modification and leg pain. It is noteworthy that simultaneous use of ginger and warfarin or heparin and aspirin increases the risk of bleeding., It also may change the effects of cardiac medications such as calcium channel blockers,, increase gastric acid production, cause problems with blood pressure and diarrhea, and if simultaneously used with antidiabetic medications may increase the risk of hypoglycemia. Therefore, given the considerable use of ginger among older adults, they should be provided with detailed information about the risks and the drug interactions associated with ginger use.
We also found a significant relationship between gender and MP use so much so that MP use by females was significantly greater than their males. Azizi-Fini et al. and Heidarifar et al. also reported the same findings. Greater MP use among women may be due to their greater attentiveness to their health. Conversely, Akbari et al. found no significant relationship between gender and MP use. This contradiction can be attributed to differences in the samples and the contexts in the studies.
Another finding of the study was the significant relationship of MP use with employment status. However, Akbari et al. reported that MP use was not significantly related to employment status. The significant relationship of MP use with employment status in the present study may be due to the significantly greater MP use among female participants and the fact that most participants were female and thereby were homemakers. In other words, homemakers constituted the largest employment status category in this study.
The study findings also showed that generally people with chronic disorders used MPs more frequently than those of without a chronic disorder. Greater MP use among patients with chronic disorders can be attributed to the too long course of these disorders, patients' dissatisfaction with conventional treatments, and their disappointment of not achieving complete recovery. An earlier study also reported that MP use is greater among patients with condition with a long course of treatment and rehabilitation.
The other finding of the study was the significant relationships of MP use with the belief in the effectiveness of MPs and the level of knowledge about MPs. Physicians participated in an earlier study also reported that people's knowledge about MPs is a major facilitating factor toward utilizing MPs. Older adults' strong belief in MP effectiveness may be due to experiences they inherited from their past generations. It is noteworthy that belief in MPs effectiveness may increase the likelihood of MP use.
This was a cross-sectional study, and although we examined some of the contributing factors of MP use, due to the nature of the study, the precise causal relationships cannot be examined in this type of studies.
The current study was conducted in Kashan city; therefore, the results cannot be fully generalized to older people in other areas. Therefore, multicenter studies are needed if national and international interventions are to be established. Furthermore, although we investigated the elderly people's expressions about the source of information about MPs and the sources which actuated them toward MP use and their beliefs about the effectiveness of MPs, qualitative studies are recommended to examine the older adults' experiences in these regards.
| Conclusion|| |
The findings of the present study showed that many older adults used MPs and firmly believed in their effectiveness. The most important sources of their MP-related information were their relatives and friends. Moreover, most of them did not report MP use to their treating physicians. These findings highlight the necessity of public education programs for informing people, particularly elderly people, about the risks associated with over-the-counter use of MPs. In addition, during medical visits, physicians and nurses need to carefully assess older adults' over-the-counter use of MPs.
We would like to profusely thank all older adults who participated in this study.
Financial support and sponsorship
This study was funded by a grant from the research deputy of Kashan University of Medical Sciences and the grant number is 9585.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adib-Hajbaghery M, Hoseinian M. Knowledge, attitude and practice toward complementary and traditional medicine among Kashan health care staff, 2012. Complement Ther Med 2014;22:126-32.
Yeo AS, Yeo JC, Yeo C, Lee CH, Lim LF, Lee TL. Perceptions of complementary and alternative medicine amongst medical students in Singapore – A survey. Acupunct Med 2005;23:19-26.
Naderifar M, Foroutan L, Kooh KA. Traditional medical practices used to treat diabetes. J Diabetes Nurs 2013;1:52-61.
Rashid MU, Eakram MS. Identification, prevalence and use of medicinal plants in fulbaria upazila of Mymensingh district. Agriculturist 2009;7:90-5.
Mwangi J, Gitonga L. Perceptions and use of herbal remedies among patients with diabetes mellitus in Murang'a North district, Kenya. Open J Clin Diagn 2014;4:152.
El-Mawla AM, Magd MS, Mahran AA. Prevalence and indication of herbal medicine in digestive system disorders in Al-Taif area, Saudi Arabia. Spatula DD 2014;4:127-30.
Mohammad Y, Al-Ahmari A, Al-Dashash F, Al-Hussain F, Al-Masnour F, Masoud A, et al.
Pattern of traditional medicine use by adult Saudi patients with neurological disorders. BMC Complement Altern Med 2015;15:102.
Ameri F, Vahabi M, Khatoonabadi S, Andalibi L. On the relevance of medicinal plants consumers in Iran: Investigating statistics for consumers, states of consumption, informative and source area. Teb Tazkiyeh 2013;22:37-42.
Akbari N, Parvin N, Sereshti M, Safdari F. Study about different types of medicinal plants used by elderly people in Shahrekord city, Iran, 2009. J Shahrekord Uni Med Sci 2011;12:26-32.
Greener M. The hidden problem of herb-drug interactions. Prescriber 2016;27:22-7.
Lunenfeld B, Stratton P. The clinical consequences of an ageing world and preventive strategies. Best Pract Res Clin Obstet Gynaecol 2013;27:643-59.
Arcury TA, Grzywacz JG, Bell RA, Neiberg RH, Lang W, Quandt SA, et al.
Herbal remedy use as health self-management among older adults. J Gerontol B Psychol Sci Soc Sci 2007;62:S142-9.
Huang AR, Mallet L, Rochefort CM, Eguale T, Buckeridge DL, Tamblyn R, et al.
Medication-related falls in the elderly: Causative factors and preventive strategies. Drugs Aging 2012;29:359-76.
Azizi-Fini I, Adib-Hajbaghery M, Gharehboghlou Z. Herbal medicine use among patients with type 2 diabetes in Kashan, Iran, 2015. Eur J Integr Med 2016;8:570-5.
Yavangi M. A Systematic review of Iranian medicinal plants effective on female infertility. J Glob Pharma Technol 2016;8:44-9.
John LJ, Shantakumari N. Herbal medicines use during pregnancy: A review from the Middle East. Oman Med J 2015;30:229-36.
Heidarifar R, Mehran N, Momenian S, Mousavi SM, Kouhbor M, Hajialigol A. A study of the status of use of drug plants and its related factors in Qom city, Iran. Qom Uni Med Sci J 2013;7:95-100.
Bakhtiari Z. The assessment of patient's satisfaction about medicinal plants in Isfahan. J Herbal Drugs 2010;1:37-9.
Ali BA, Mahfouz MS. Herbal medicine use among patients with type 2 diabetes in North Sudan. Annu Res Rev Biol 2014;4:1827-38.
Wazaify M, Afifi FU, El-Khateeb M, Ajlouni K. Complementary and alternative medicine use among Jordanian patients with diabetes. Complement Ther Clin Pract 2011;17:71-5.
Nyeko R, Tumwesigye NM, Halage AA. Prevalence and factors associated with use of herbal medicines during pregnancy among women attending postnatal clinics in Gulu district, Northern Uganda. BMC Pregnancy Childbirth 2016;16:296.
Salih N, Al-Asadi JN. Herbal remedies use among diabetic patients in Nassyria, Iraq. World Fam Med J 2012;10:40-6.
Chang HY, Wallis M, Tiralongo E. Use of complementary and alternative medicine among people with type 2 diabetes in Taiwan: A cross-sectional survey. Evid Based Complement Altern Med 2011;2011:983792.
Ali-Shtayeh MS, Jamous RM, Jamous RM. Complementary and alternative medicine use amongst Palestinian diabetic patients. Complement Ther Clin Pract 2012;18:16-21.
Abdullah Al-Rowais N, Al Bedah AM, Khalil MK, El Olemy AT, Khalil AA, Alrasheid MH, et al.
Knowledge and attitudes of primary health care physicians towards complementary and alternative medicine in the Riyadh region, Saudi Arabia. Forsch Komplementmed 2012;19:7-12.
Awodele O, Agbaje E, Abiola O, Awodele D, Dolapo D. Doctors' attitudes towards the use of herbal medicine in Lagos, Nigeria. J Herb Med 2012;2:16-22.
Izzo AA. Interactions between herbs and conventional drugs: Overview of the clinical data. Med Princ Pract 2012;21:404-28.
Du Y, Wolf IK, Zhuang W, Bodemann S, Knöss W, Knopf H, et al.
Use of herbal medicinal products among children and adolescents in Germany. BMC Complement Altern Med 2014;14:218.
Laelago T, Yohannes T, Lemango F. Prevalence of herbal medicine use and associated factors among pregnant women attending antenatal care at public health facilities in Hossana town, Southern Ethiopia: Facility based cross sectional study. Arch Public Health 2016;74:7.
Vosough A, Khomeyri M, Kashaninezhad M, Seyed M. Effects of mint extract on the viability of probiotic bacteria in a native Iranian dairy drink (doogh). J Agric Sci Nat Resour 2009;16:156-64.
Mashhadi NS, Ghiasvand R, Askari G, Hariri M, Darvishi L, Mofid MR, et al.
Anti-oxidative and anti-inflammatory effects of ginger in health and physical activity: Review of current evidence. Int J Prev Med 2013;4:S36-42.
Ge B, Zhang Z, Zuo Z. Updates on the clinical evidenced herb-warfarin interactions. Evid Based Complement Alternat Med 2014;2014:957362.
Kaye AD, Baluch A, Kaye AM. Mineral, vitamin and herbal supplements. In: Fleisher LA, editor. Anesthesia and Uncommon Diseases. 6th
ed. Philadelphia: Elsevier; 2012.
Zhang Y, Leach MJ, Hall H, Sundberg T, Ward L, Sibbritt D, et al
. Differences between male and female consumers of complementary and alternative medicine in a national US population: A secondary analysis of 2012 NIHS data. Evid Based Complement Alternat Med 2015;2015:1-10.
Rashrash M, Schommer JC, Brown LM. Prevalence and predictors of herbal medicine use among adults in the united states. J Patient Exp 2017;4:108-13.
Hilal M, Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-sectional study. J Assoc Arab Univ Basic Appl Sci 2017;24:325-33.
[Table 1], [Table 2], [Table 3], [Table 4]